INSTITUTIONAL ETHICS

1014

poisoning, and violence-were similar whether prisoners were given short (SMR 84) or long (SMR 85) sentences. To analyse whether the mortality of people who had been in prison from before 1977 had a residual effect on the data, mortality rates were compared for two different periods. The SMR for 1977-79 was similar to that for 1980-83 (94 =

=

and 91, respectively). Our choice of prison population for this study restricted the number of deaths from unspecified causes to a minimum and meant that records of causes of death were accurate. Medical services in prisons are provided by general practitioners. Death certificates are filled out as or even more precisely in prison than outside, necropsy (rare for the general population in France) always being done when the cause of death is unknown. Mortality from all causes was lower, although not significantly so, among prisoners than in the general population. The larger-than-expected number of suicides and smaller-than-expected number of deaths due to accidents, poisoning, and violence were not a surprise. The striking feature was the lower-than-expected mortality from all except external causes, whereas a higher mortality rate would have been expected because of probable overconsumption of tobacco and alcohol before and during imprisonment (purchase of tobacco is not limited although purchase of alcohol is, to one can of beer per day). A higher mortality rate would also be expected if prisoners are assumed to belong to the lower social classes. There is the possibility that healthy persons are at higher risk of imprisonment than persons in poor health, analogous to the "healthy worker effect" observed in occupational studies. However, the overall overmortality from cardiovascular diseases among prisoners contradicts this

assumption. The decrease in mortality rates with increased duration of imprisonment for all major causes of death, including cardiovascular diseases, suggests that the reduction may to some extent be due to the lifestyle in detention, perhaps also to the very high consumption, in prison, of tranquillisers, for which an antitumour-promoting effect has been

suggested.10,11 This work was supported by a grant from the Caisse Nationale d’Assurance Maladie des Travailleurs Salaries and from the Institut National de la Sante et de la Recherche Medicale. We thank Dr Ariane Auquier for her critical comments.

Correspondence should be addressed to F. C., INSERM U287, Instirut Gustave Roussy, Rue Camille Desmoulins, 94805 Villejuif, France. REFERENCES 1 Rabkin JG, Struening EL. Life events, stress and illness Science 1976; 194: 1013-20. 2. Grinker RR. Psychosomatic aspects of the cancer problem. Ann NY Acad Sci 1966;

125: 876-82. 3 Donaldson M. Cancer, the psychological disease. Lancet 1955;i. 959. 4. Kay N, Allen J, Morlay JE. Endorphins stimulate normal human penpheral blood lymphocyte natural killer activity Life Sci 1984; 35: 53-59. 5. Le Goaster J, Le Magnen J. Neurobiology and cancer. possible role of &bgr;-endorphins m cancer growth regulation. Cancer J 1987, 1: 204-07 6 Copeland AR. Deaths in custody revisited. Am J Forensic Med Pathol 1984; 5: 121-24. 7. Novick LF, Remmlinger E. A study of 128 deaths m New York City correctional facilities (1971-1976): implications for prisoner health care. Med Care 1978, 16: 749-56 8. International Classification of Diseases, ninth revision. Geneva: World Health Organisation, 1977. 9. US Department of Health and Human Services. Conversion of neoplasm section, 8th revision of International Classification of Diseases (1965) to neoplasm section, 9th revision of International Classification of Diseases (1975). Percy C, ed Bethesda NIH Publication No 82-2448, 1981 10. Schatzman RC, Wise BC, Kuo JF. Phospholipid-sensitive calcium-dependent protein kinase. inhibition by antipsychotic drugs. Biochem Biophys Res Commun 1981; 98: 669-76. 11. Castagna M, Takai Y, Kaibuchi K, Sano K, Kikkawa U, Nishizuka Y. Direct activation of calcium-activated phospholipid-dependent protein kinase by tumorpromoting phorbol esters. J Biol Chem 1982; 257: 7847-51.

Health Watch INSTITUTIONAL ETHICS THE changing relationship between doctors and patients in the United States shows itself in many ways. In addition to the evidence of the malpractice suits, there is a multiplication of organisations and publications aimed at weaning people away from reliance on the medical profession. Healers abound, from cynical quacks to the sincerely addle-headed. Social activist groups attack physicians for their resistance to public accountability. Somewhere in the rational middle are those who believe that licence to practise should depend on periodic professional re-examination for competence. What unites these disparate groups is dissatisfaction with the institutional reliability of the medical profession. Eighty years ago when Shaw accused the professions of being conspiracies against the laity, he was expressing an amusing, if not entirely acceptable notion. Today’s generation, nourished on scandalous revelations of misconduct, abuse of trust, and mistreatment, holds that notion as a truism. There is enough evidence of chicanery to make us all sceptics and doubters. Yet in some degree the attacks on the physicians are prompted also by the high costs of medical practice. How should the medical profession respond? At bottom, what is at issue is the defmition and application of the term profession. From ancient times, when medicine was magical and religious and physicians were priestly surrogates, medical practice was defined, practised, and supervised by the religious order itself. Later the guilds took over responsibility for defming the boundaries of medicine, granting permission to practise, and supervising the practitioners. When, a few hundred years ago, government undertook licensure, the aim was only to protect the populace from untrained practitioners; responsibility for quality was left with the profession itself. Today, the Government is being pressed to enforce competent, concerned, and ethical behaviour upon physicians. The ancient duty of the medical profession to defme and police itself is to be withdrawn. As Carleton Chapman writes, "It is abundantly clear that although the tribal concept of craft and craft-oriented codes has endured over an astonishingly long period, it has now had its day."1 Responsibility for this lies far more with the medical organisations, who have failed to ensure the competence and reliability of their members, than with the anti-intellectual and anti-scientific critics or the politicians in search of more economical practitioners. The teaching medical centres have withdrawn themselves from the daily give-and-take of patient care where much of the public attitude toward medicine and physicians is developed. However intensively these centres may be engaged in medical care, the technological complexity of their activities tends to eliminate the personal interactions from which good doctor/patient relationships develop. Moreover, research in these institutions ignores the dilemmas of practice, the qualifications of the practitioners, and the requirement for doctors who will respond flexibly to changing social and patient needs. Such studies-the applied mechanics of medical practice=are scorned as beneath the scientific concerns of the teaching centres. As to the doctors’ associations, they are preoccupied with maintaining the

1015 status quo in

practice and ensuring proper financial returns physicians. The changing needs of medical practice are left to the scholarly skills of sociologists, economists, and

to

administrative managers. The result has been a bonanza for graduate students in the various academic disciplines, and a disaster for practising physicians and their patients.2 Does this mean that a return to the good old guild and craft days is the answer? Of course not. But it does mean that

physicians’ organisations, the professional associations, and the teaching medical institutions have to rechart their First of all, they must begin to demonstrate a real for and involvement in the problems of medical practice, and bring along their constituency in that regard. If periodic reassessment of practitioners is necessary and desirable, much more than government examinations is needed. Continuing education has to be more than a lecture or attendance at a clinic. A whole new approach to continuing education will involve university courses, regular attendance for shorter or longer periods, and preparation for the examinations in thoughtful and logical ways. How will doctors be reimbursed for the time they will be expected to spend in such study? What about replacements during that time? Where will that money come from? The doctors will be expected to learn the new ideas and the new techniques, and to be acquainted with the course.

concern

Round the World From

our

Correspondents

United States LITTLE NEUTRALITY IN CONFLICT OVER ACID RAIN

President Reagan has successfully resisted all entreaties to reduce acid rain. He has turned aside proposals by members of Congress and rejected another by his own environmental chief. The electric power and coal industries-the source of most of the sulphur dioxide that acidifies the rain-stand four-square behind the President. The latest "all’s well" message comes from a group called the National Acid Precipitation Assessment Program. An interim report, at the halfway point of a 10-year study, fmds little evidence of an immediate threat to the environment or public health. The authors say a few lakes have been damaged but "there will not be an abrupt change in aquatic systems, crops or forests at present levels of air pollution". The director of research and spokesman for the study is J. Laurence Kulp, a former science professor at Columbia University, who later worked as a scientist for the Weyerhaeuser Company, a large wood products firm. He described the study as a "state-of-the-science documentnot a policy document at all". Some environmentalists don’t believe it. "It is in fact nothing more than political propaganda for the Reagan administration," according to Richard E. Ayres, senior attorney for an environmental organisation called the National Resources Defense Council. "Scientific studies inconsistent with the administration’s political line are ignored or disparaged. Others are selectively quoted to minimise the problem. Untested hypotheses consistent with administration politics are described as fact." One of the many points in contention is that the report listed as acidic only lakes and streams with a pH of 5-0 or lower-on the grounds that at this level of acidity the water fails to support fish life. That considerably understates the problem, in the view of Eville Gorham of the University of Minnesota, who has monitored lake acidity in the US upper midwest. Biologists, he notes, have observed aquatic damage at pH levels of 55 or even as high as 6-0. In the Adirondack Mountains in New York state, for example, only 10% of the lakes are below 5-0, but 27% are below 6-0%. FOR seven years,

that underpins them. Those academic institutions who claim leadership in medicine should now be hard at work devising a system whereby practitioners can maintain the skills and excellence that are fostered in medical schools. Secondly, practitioners should be encouraged to look critically at what they themselves are doing, in terms of the need of people for care and cure. The self-scrutiny that began with the clinical-pathological conferences and infant and maternal mortality conferences needs to be extended to the daily practice of medicine. More and more doctors are being taken into the corporate camp, the link to individual responsibility is being dissolved, and the medicine now promoted by government and business alike is one of economic controls, average utility, and bottom-line cost benefits. Unless the institutions that represent the ethos of medicine reform themselves, the physician may become just one on a roster of "healers", with unhappy consequences for doctors and patients.

knowledge

590 Ellsworth

GEORGE SILVER,

New

Professor Emeritus of Public Health

Ave, Haven, CT06511,

USA

CB. Physicians, law, and ethics. New York: New York University Press, 1984. 2. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Securing access to health care, vol 3. Washington, DC: US Government Printing Office. 1.

Chapman

The Canadian Government is responding to the report as the latest US slap in the face. Some time ago the Reagan Government classified three Canadian acid-rain documentary movies as political propaganda (the same label Canadian Government officials apply to the new report). Then the Canadians hired President Reagan’s longtime friend and adviser, Michael Deaver, as a lobbyist to push reductions of acid rain after he left the White House. Deaver was no help, and now stands indicted by a grand jury for perjury-for, among other things, concealing his conflict of interest in dealing with Canada. President Reagan caused Canada further consternation after a meeting with the Canadian Prime Minister, Brian Mulroney, by promising a multi-million-dollar acid-rain research program that has never materialised. Finally, the new report-called "voodoo science" by the Canadians-ignores Canada’s acid-rain troubles. A source of puzzlement about the new study is that previous Government reports have generally found that acid rain damages health and the environment. One such study was conducted by the National - Academy of Sciences. An investigator for the Government’s General Accounting Office has discovered that at one point the directors of the new study negotiated with the Academy to provide a review committee. Talks broke down because the Academy insisted on complete independence. One Reagan administration objection was that the Academy had members who "have expressed their views on the need to control acidic deposition ... and therefore cannot be considered neutral". ,

AIDS AND EDUCATION

If the AIDS epidemic is to be limited, children must be educated about its aetiology. For years sex education in schools has tried to cope with teenage pregnancy despite strong opposition from religious groups and other interested individuals. Schools and their curricula are locally controlled, and there have been many restrictions on sex education. But the epidemic has forced much rethinking by the opponents of sex education, and more adventurous thinking by its proponents. There is now widespread agreement that more sex education in schools is imperative, a proposal advocated even by the former opponent, the surgeongeneral. There are two components to the school programmes: education in sex and sexuality; and provision of contraceptives. Condoms are now readily available in schools and colleges. How the issue will be settled is not clear, especially in view of a forthcoming Papal visit.